Relapse of severe acute malnutrition post-discharge from outpatient programs among children recovered from complicated SAM in a conflict-affected setting: a matched cohort study, Sana’a, Yemen

Little evidence exists on post-discharge outcomes and the sustainability of recovery among children recovering from complicated severe acute malnutrition (SAM). This study assessed the incidence and predictors of SAM relapse and patterns of nutritional status over time among children discharged from outpatient therapeutic programs (OTPs) in Sana’a, Yemen. A prospective cohort study followed 148 children (74 post-SAM and 74 community controls) at 3, 6, and 9 months post-discharge from OTP. Incidence rates of SAM and moderate acute malnutrition (MAM) were calculated. Poisson regression with generalized estimating equations estimated incidence rate ratios (IRRs) for SAM and MAM. Among post-SAM children, competing-risk regression was performed, treating first MAM as a competing event for SAM relapse, to estimate sub-hazard ratios (SHRs). At 6 months, 36% of post-SAM children experienced SAM compared with 9% of controls, rising to 45% versus 14% at 9 months. MAM occurred in 58% of post-SAM children versus 20% of controls. Adjusted Poisson regression showed higher SAM incidence among post-SAM children (IRR = 2.57; 95% CI: 1.11–5.93), with incidence peaking at six months (IRR = 2.20; 95% CI: 1.12–4.33). Lower baseline weight-for-height z-score (WHZ) was protective (IRR per 1-unit increase = 0.70; 95% CI: 0.51–0.96), while fever increased SAM incidence (IRR = 2.60; 95% CI: 1.59–4.20). MAM incidence did not differ significantly between groups (IRR = 1.60; 95% CI: 0.86–2.97) but was predicted by fever (IRR = 2.20; 95% CI: 1.43–3.37) and diarrhea (IRR = 1.70; 95% CI: 1.20–2.48). Competing-risk regression confirmed lower baseline WHZ (SHR = 0.67) and fever (SHR = 2.41) as predictors of SAM relapse. The hazard of relapse to SAM was significantly lower at nine months compared with three months (SHR = 0.27). Children recovering from complicated SAM remain vulnerable to recurrent acute malnutrition after discharge. These findings support extended post-discharge monitoring, early management of acute illnesses, and better integration of MAM services within routine care, particularly in fragile settings. Further research is needed to guide optimal discharge criteria and post-discharge support strategies.